Clinical Resource Manager

IHA; Boise (ID); On-site; USD 70,000 - 100,000; Full time

Job summary

Saint Alphonsus Health System seeks a Clinical Resource Manager to lead hospital case management, utilization review, and discharge planning. You will collaborate with physicians, social services, and care teams to determine level of care and ensure smooth transitions beyond acute care.

Strong focus on regulatory compliance and cost-effective care planning. Requirements include an RN license in Idaho or Oregon, BSN, 2+ years hospital clinical experience, and knowledge of case management.

Qualifications

• RN license in Idaho or Oregon as defined by primary state.
• If relocating to Idaho from another compact state, licensure by endorsement and change of residence within 60 days.
• Provide licensure proof for secondary state within 90 days of hire.
• BSN required; master's degree preferred.
• Minimum 2 years varied hospital clinical experience required.
• Experience in case management, home health, or the insurance industry preferred.

Responsibilities

• Knows, understands, and demonstrates the Organization's Mission, Vision, and Values.
• Care for diverse age groups per patient need and plan.
• Revenue management: document services and supplies accurately.
• Coordinate social services/case management with hospital departments and external partners.
• Screen and assess physician cases for medical necessity and transition needs.
• Conduct concurrent medical record review to determine appropriate care level.
• Educate health care team on regulatory standards and requirements.
• Promote efficient utilization of clinical resources from admission to discharge.
• Engage in discharge planning and patient/family education for post-acute needs.
• Ensure compliance with Medicare/participation standards and Joint Commission.

Skills

RN license

Communication

Clinical coordination

Regulatory awareness

Education

BSN

Master's degree (preferred)

Job description

Summary

Provides hospital case management/utilization review and discharge planning collaboratively determining level of care needs beyond acute care, providing decision support to patients/families and physicians, managing patient and family expectations, and ensuring a smooth transition to the next level of care and services. Coordinates the integration of social services into patient care as appropriate. Coordinates the hospital activities concerned with case management/utilization review and discharge planning. Adheres to departmental goals, objectives, standards of practice, and policies and procedures. Ensures quality patient care and adheres to regulatory compliance. Provides concurrent assistance and support to physicians and other clinical members of the health care team in coordinating the delivery of services for a select group of patients. To help achieve quality clinical and cost outcomes, incorporates real-time contacts with physicians, nursing, and ancillary care givers to establish specific treatment, cost, and transition targets and to facilitate transition planning.

Employment Type

Full time

Shift

Day Shift

Description

CLINICAL RESOURCE MANAGER

Summary

Provides hospital case management/utilization review and discharge planning collaboratively determining level of care needs beyond acute care, providing decision support to patients/families and physicians, managing patient and family expectations, and ensuring a smooth transition to the next level of care and services. Coordinates the integration of social services into patient care as appropriate. Coordinates the hospital activities concerned with case management/utilization review and discharge planning. Adheres to departmental goals, objectives, standards of practice, and policies and procedures. Ensures quality patient care and adheres to regulatory compliance. Provides concurrent assistance and support to physicians and other clinical members of the health care team in coordinating the delivery of services for a select group of patients. To help achieve quality clinical and cost outcomes, incorporates real-time contacts with physicians, nursing, and ancillary care givers to establish specific treatment, cost, and transition targets and to facilitate transition planning.

Requirements

• Colleague must have an RN license, as defined by their primary work state (Idaho or Oregon)
• IDAHO ONLY: If a nurse moves to Idaho from another compact state, they must apply for licensure by endorsement and update their primary state of residence to Idaho within 60 days of being hired.
• All colleagues must provide licensure or proof of application for secondary state within 90 days of hire.
• BSN required. A master's degree is preferred.
• A minimum of 2 years of varied hospital clinical experience is required.
• Experience in case management, home health, and/or the insurance industry preferred.

What You Will Do

• Knows, understands, incorporates, and demonstrates the Organization's Mission, Vision, and Values in behaviors, practices, and decisions.
• Demonstrates knowledge and skills to competently care for all assigned age groups (Neonate, Child, Adolescent, Adult, Geriatric as applicable).
• Revenue Management: ensures the accuracy of documenting services and supplies provided to the patients.
• Coordinates the integration of social services/case management functions into patient care, discharge, and home planning process with other hospital departments, external service organizations, agencies and healthcare facilities.
• Completes a screening/assessment of physician assigned cases to determine medical necessity/status determinations and transition needs. Reassesses, monitors, and modifies transition needs as appropriate.
• Conducts concurrent medical record review using established medical necessity criteria to determine correct level of care for acute patients. Assists physicians with completing transfer and discharge orders. Maintains knowledge of federal, state, and private agency review requirements and regulations.
• Provides education to all health care team members including physicians regarding requirements to meet regulatory standards.
• Promotes effective and efficient utilization of clinical resources from admission to discharge.
• Initiates and presents "denial letters" as appropriate. Completes PASRRs for admission to skilled nursing facilities. Delivers Condition Code 44 letters to patients and educates them on Medicare benefits.
• Researches and locates resources for patients for example: assistance in competing medication applications for financial assistance through pharmaceutical companies, works closely with our Patient Financial Advocates in the Medicaid pending process, and works closely with outside facilities to obtain equipment in situations when patients have limited funding available to them.
• Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assists physicians to maintain appropriate cost, cases, and desired patient outcomes.
• Introduces self to patient and family and explains clinical resource manager role and the process for patient and family to contact clinical resource manager.
• Serves as a patient advocate. Enhances a collaborative relationship to maximize the patient's and family's ability to make informed decisions.
• Participates in multidisciplinary patient care rounds and/or conferences as appropriate to review treatment goals, optimize resource utilization, provides family education and identification of post-hospital needs.
• Utilizes physician advisor referral as appropriate.
• Adheres to department established process in reviewing 30 day re-admissions.
• Follows established patient choice policy.
• Documents assessment of primary and back up plans along with communications to patient, family and care team.
• Documents interventions taken to meet the needs of their individual patients in Power Chart.
• Actively participates in department staff meetings and department sub teams.
• Ensures discharge planning compliance with Medicare Conditions of Participation/regulations and Joint Commission standards.

Colleagues of Saint Alphonsus Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout SAHS and Trinity Health.

Saint Alphonsus and Trinity Health are committed to promoting diversity in its workforce and to providing an inclusive work environment where everyone is treated with fairness, dignity and respect. We are committed to recruit and retain a diverse staff reflective of the communities we serve. Saint Alphonsus and Trinity Health are equal opportunity employers and prohibit discrimination against any individual with regard to race, color, religion, gender, marital status, national origin, age, disability, sexual orientation, or any other characteristic protected by law.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.